Effects of White Noises on Gait Ability of Hemiplegic Patients during Circuit Balance Training
This study examines the effects of different environments on the application of hemiplegia patients circuit balance training. Group 1 performed circuit balance training without any auditory intervention Group 2 performed training in noiseless environments and Group 3 performed training in white noise environments. First, among lower extremity muscular strength evaluation items, maximum activity time(MAT) was not significantly different(p>.05). Maximum muscle strength(MMS) increased significantly in Group 3(p<.01), there was no significant difference in MMS among the groups. Average muscle strength(AMS) indexes also significantly increased in Group 3(p<.01), there was no significant difference in AMS among the groups.
Second, among balancing ability evaluation items, Berg's balance scale(BBS) scores significantly increased in all groups(p<.05), BBS scores were significantly difference among the groups. Based on the results, Group 1, 2 and Group 1, 3 showed significant increases (p<.05). Functional reach test(FRT) values significantly increased in Group 2, 3(p<.05), and there was no significant difference in FRT val- ues among the groups. Timed up and go(TUG) test values signifi- cantly decreased in Group 2, 3(p<.05), and there was no significant difference in TUG test values among the groups. Third, among walk- ing speed evaluation items, the time required to walk 10m significant- ly decreased in all groups(p<.05), and there was no significant differ- ence in the values among the groups. Average walking speeds showed significant increases in Group 1, 3(p<.05), and there was no significant difference in the values among the groups. Based on the results of this study, noise environments should be improved by either considering auditory interventions and noiseless environments, or by ensuring that white noise environments facilitate the enhance- ment of balancing ability.
Key words:White Noise; Circuit Balance Training; Gait Ability
Na Young Janga, Gi Do Kimb, Bo Kyoung Kimb, Eun Hee Kimb, Ja Pung Kooc, Hee Joon Shind, Seok Joo Choie, Wan Suk Choib
aChangwon General Hospital, Changwon;
bInternational University of Korea, Jinju;
cPohang College, Pohang; dKyungwoon University, Gumi; eDaegu Science University, Daegu, Korea
Received : 9 November 2011 Accepted : 21 February 2012 A
Addddrreessss ffoorr ccoorrrreessppoonnddeennccee Wan Suk Choi, PT. Ph.D
Department of Physical Therapy, International University of Korea, 965 Dongbu-ro, Munsan-eup, Jinju, Korea Tel: 82-55-751-8293
E-mail: [email protected]
Stroke patients are at high risk of injuries from a fall or secondary damages due to balance disorder resulting from cognitive function decrease, orienta- tion disturbance, reduction in motor ability, and decrease in proprioceptive and position senses(1).
Balance involves integration of visual, auditory,
and vestibular stimuli and those delivered by propri- oceptive and sensory receptors in the central nervous system, and functional factors such as visual spatial recognition, muscle tone that responds to environ- mental changes swiftly and precisely, muscle strength, endurance, and joint mobility engage in balance; Disorder in one of these factors may result in loss of balance performance ability(2, 3).
Reactionstoauditorystimuliaredifferentfromthose
INTRODUCTION
to visual or olfactory stimuli. Repetitive auditory stimuli are delivered to the reticular formation of brainstem without the cognitive process directed by the cerebral cortex, thereby resulting in body move- ments through nerve cells of the spinal cord motor system(4, 5).
The brain areas involving concentration include the prefrontal lobe, posterior cortical, and thalamic areas(6). Hemiplegic patients needed to exert con- centration in order to maintain their postures(7) and subacute stroke patient's postural stability was in proportion to their visual and auditory concentra- tion(8). In high intensity noises, their intensity itself was a very important variable in task performance but in low intensity noises, their predictability more greatly influenced task performance than their intensity; auditory stimuli like white noises with repetitive frequency wave forms in a general noise environment of between 60dB and 80dB increased concentration and adaptability, thereby resulting in improved task performance(9). Therefore, auditory stimuli that help to improve concentration may sig- nificantly influence balance adjustment or motor learning in patients with hemiplegia resulting from stroke and environmental constraints to motions should be considered in a motor learning process(10).
Meanwhile, a circuit walking program be applied to stroke patients in order to improve balance, mobility, muscle strength, and function activities(11). Circuit training was conducive to increasing muscle strength as one of exercises recommended for stroke patients (12). Training patients on tasks appropriate for them in a lump is an effective and clinically easy way to apply task-oriented training(13, 14, 15). Diverse ele- ments are included in a treatment environment: the size of treatment space, intensity of illumination, and moving line(10). Noise is also one of important ele- ments. However, there is no environmental regulation for rehabilitation treatment and facilities of treatment rooms are equipped without any clear standard. In particular, there has been some research on interior design or environmental composition of play therapy rooms for children(16), but relevant studies on adults or the elderly are lacking.
Accordingly, this study aimed to examine effects of circuit balance training on lower limb muscle strength, balance adjustment capabilities, and gait velocity of hemiplegic patients in a general noise environment, artificial no-noise environment, and white noise environment which has been proven to enhance concentration and efficient muscle move- ments, and to provide basic materials for future environmental regulations on treatment rooms.
The subjects were 25 patients who were hospital- ized at E long term care hospital located in Jinju-si and voluntarily consented to participate in this study. They were assigned to one of three groups;
they were made to be homogeneous as much as pos- sible in consideration of the subjects disease dura- tions. The group 1 was trained without auditory intervention during circuit balance training. The group 2 was trained under a non-noise environment.
The group 3 was trained under a white noise envi- ronment. The criteria for selection as a subject were:
chronic patients who were diagnosed with hemiplegia caused by stroke and whose onset period ranged from six months to 24 months; those who did not have cognitive impairment, with their Korean mini- mental state examination(K-MMSE) scores at 24 points or higher; and those who had no auditory impairment within the recent two years; and those who did not use any aid or were able to walk 10m with an aid.
Sufficient explanation on the circuit balance training was made to physical therapists with at least three years of working experiences and how to conduct it was shown to them. The same physical therapists applied training to the subjects for 7 weeks. The researcher referred to the circuit balance training program proposed by Carr and Shepherd(17) and the subjects were made to conduct six different tasks.
For five minutes prior to the initiation of this train- ing, the subjects conducted warm-up exercise for themselves. They took a rest for 1 minute between tasks in order to minimize their fatigue. They per- formed training 5 times per week for a total of 7 weeks. When necessary, the intensity of tasks was heightened in consideration of the subjects condi- tions. The 6 exercises were: 1) sitting down on and standing up from a mat of diverse height; 2) stand- ing on a balance board; 3) walking on a treadmill; 4) walking following patterns on the ground; 5) going up and down the stairs of 7cm height each; 6) throwing a sand bag on a treatment ball. Each group's changes in the results prior to and after the program were compared and analyzed.
Subjects
Procedure
METHODS
A double-blind clinical test was performed regard- ing all functional evaluations. Two physical thera- pists who received training in advance conducted measurements and calculated mean values.
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Walking Man II(CyberMedic Inc., Korea) was used to measure lower limb muscle strength. The rectus femoris among the quadriceps which it was easy to apply electromyography was selected as a measure- ment area. For maximum isotonic contraction, the subject sat on a backless mat of knee height and bended the trunk sidebending with the knee joint at 90 degrees and stretched and maintained the knee of the affected side. A surface electrode was used as a recording electrode. In order to minimize skin resist- ance, the attachment area was washed with alcohol.
The connection cable jacks were connected to the cable in the order of red, black, and gray ones. 3 items maximum activity time(MAT), maximum muscle strength(MMS), and average muscle strength(AMS) werestatisticallyanalyzed.
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The Berg balance scale(BBS), functional reach test(FRT), and timed up and go test(TUG) were per- formed to evaluate the subjects dynamic balance, standing postural balance, and gait balance, respec- tively.
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For gait speed, 10m-timed walk test was per- formed; the time taken to walk 10m and average velocity were estimated.
The collected data were encoded and SPSS 18.0 was used for statistical analysis. A non-parametric test was carried out to analyze post-training changes in the evaluated items. A Wilcoxon signed ranks test was conducted to examine each groups post-training changes in muscle strength of the lower extremity of the affected side, balance adjustment capabilities, and gait velocity. The Kruskal Wallis test was used to compare post-training changes in the evaluated items between the groups. The Bonferroni post hoc test was applied to significantly different results among the groups. The results of this study were presented α=.05 was considered statistically signifi- cant.
The subjects average age was 67.29±12.51 years old in the group 1, 67.33±7.94 years old in the group 2, and 64.67±10.71 in the group 3. Their onset dura- tion was 19.14±5.43 months in the group 1, 22.00± 2.40 months in the group 2, and 21.78±2.64 months in the group 3(Table 1).
Changes in lower extremity muscle strength of the affected side after the training were examined and the result was that MAT increased in the groups 1 and 2 but decreased in the group 3, which was not statistically significant(Fig. 1).
General Characteristics of Subjects
Changes in L/E Muscle Power
Data Analysis
Measurement
RESULTS
Age(yrs)
K-MMSE(score) Onset duration
(months)
67.29±12.51 19.14±5.43 27.71±1.89
67.33±7.94 22.00±2.40 28.44±1.88
64.67±10.71 21.78±2.64 28.11±1.45 Group 2
Group 1
Group
Group 3 T
Taabbllee 11.. General characteristics of subjects (Mean±SD)
F
Fiigg.. 11.. Changes in MAT
MMS showed no statistically significant changes in group 1 and 2 but group 3 showed their MMS values significantly increase from 66.00±77.60㎶ to 93.78±
92.80㎶(p<.01)(Fig. 2).
AMS did not significantly differ between prior to and after the training in group 1 and 2 but it signifi- cantly increased after the training from 50.67±
6.84% to 57.22±8.09% in group 3(p<.01)(Fig. 3).
Changes in balance adjustment capabilities after the training were examined and the result was that BBS scores significantly increased from 31.00±8.35
points to 33.00±8.04 points in group 1(p<.05), from 34.78±10.27 points to 41.56±5.83 points in group 2(p<.01), and from 31.33±7.42 points to 45.11±4.51 points in group 3(p<.01)(Fig. 4).
After the 7 weeks training, balance adjustment capabilities of the 3 groups were compared and ana- lyzed, with significant increases in BBS and in group 1 and 3 and group 2 and 3 in the post hoc test result.
F
Fiigg.. 22.. Changes in MMS
F
Fiigg.. 33.. Changes in AMS
F
Fiigg.. 55.. Changes in FRT F
Fiigg.. 44.. Changes in BBS
a: between-groups (group1 & group2) b: between-groups (group1 & group3) c: between-groups (group2 & group3)
Changes in Balance Control Ability
**: p<.01
**: p<.01
*: p<.05, **: p<.01
*: p<.05, **: p<.01
FRT of group 1 increased after the training but the change was not statistically significant. On the other hand, after training FRT significantly increased from 90.16±12.67cm to 94.44±13.28cm in group 2(p<.05) and from 91.25±9.52cm to 99.17±9.45cm in group 3(p<.01)(Fig. 5).
The TUG of group 1 slightly decreased after the training and the change was not statistically signifi- cant. The TUG of group 2 was 43.00±25.75 seconds prior to the training statistically significantly decreased to 39.87±26.28 seconds(p<.05). Likewise, the TUG of group 3 also statistically significantly decreased from 49.00±18.44 seconds to 30.85±12.74 seconds after the training(p<.01)(Fig. 6).
Changes in gait velocity in the 10MTW test through circuit balance training were examined. Gait velocity statistically significantly decreased from 56.14±52.19 seconds to 51.65±52.80 seconds(p<.05) in group 1, from 42.45±30.15 seconds to 39.83±29.81 seconds(p<.05) in group 2, and from 40.88±26.21 seconds to 29.15±20.06 seconds in group 3(p<.05) after the training(Fig. 7).
Average velocity significantly increased from .35
±.27 m/s to .44±.33 m/s(p<.05) in group 1 and .35
±.21 m/s to .52±.34 m/s(p<.05) in group 2. Although group 3 average velocity also increased after the training but the change was not statistically signifi- cant(Fig. 8).
Task-oriented circuit exercise improved acute stroke patients gait ability(18) and subacute stroke patients gait endurance, sense of balance, and motor function(19). Such exercise also enhanced sitting and standing ability and gait velocity of stroke patients whose duration of the disease was one year or longer(20). Programs to increase muscle strength of the lower extremities, gait balance, gait velocity, and gait distance were very effective to stroke patients, and weakened muscle of the lower extremities may greatly affect their body support, balance, and movement(15). Joo applied task-oriented circuit training to stroke patients for 40 minutes each time, twice per week, for a total of six weeks(21). In this study, the training was applied for 35 minutes each F
Fiigg.. 66.. Changes in TUG
F
Fiigg.. 77.. Changes in 10MTW lead time Changes in Gait Speed
F
Fiigg.. 88.. Changes in 10MTW average velocity
DISCUSSION
*: p<.05, **: p<.01
*: p<.05, **: p<.01
*: p<.05, **: p<.01
time, five times per week, for a total of seven weeks.
MMS of the rectus femoris of the affected side sig- nificantly increased from 66.00±77.60㎶ to 93.78±
92.80㎶ in group 3(p<.01) and AMS significantly increased from 50.67±6.84% to 57.22±8.09% in group 3 as well(p<.01). Kim applied proprioceptive neuromuscular facilitation(PNF) exercise and circuit exercise programs to chronic stroke patients and compared and analyzed their balance, gait, motor function and EMG results of the quadriceps femoris;
the circuit exercise group saw their muscle activities increase from 3.06±5.11% to 4.42±9.66%, which was not statistically significant(p>.05)(22). All groups saw their BBS significantly increase from 31.00±8.35 points to 33.00±8.04 points in group 1(p<.05), from 34.78±10.27 points to 41.56±5.83 points in group 2(p<.01), and from 31.33±7.42 points to 45.11±4.51 points in group 3(p<.01). 7 weeks after the training, BBS showed significant differences among the 3 groups, with significant increases in group 1 and 2 and in group 1 and 3 in the post hoc test. This result means that non-noise and white noise environments are more effective than an environment without auditory intervention in improving balance adjust- ment capabilities. Leroux et al. observed that task- oriented training applied to chronic stroke patients significantly increased their BBS from 48.3±5.9 points to 51.1±5.1 points (p<.05)(23). Lee and Kim also reported that task-oriented circuit training for balance improvement significantly increased patients BBS from 43.20±10.50 points to 49.70±4.40 points(24), which was consistent with the present study result(p<.05).
The functional reach test reflected endurance, muscle strength, flexibility, and postural adjustment mechanisms(25). Task-oriented training to improve forward reach position was useful in treating stroke patients(26). In this study, group 1 FRT was not sta- tistically significantly different between prior to and after the training(p>.05), which was consistent with prior study results. On the contrary, FRT signifi- cantly increased from 90.16±12.67cm to 94.44±
13.28cm(p<.05) in group 2 and from 91.25±9.52cm to 99.17±9.45cm in group 3(p<.01), with better results than in an environment without auditory interven- tion. Lee and Kim observed that patients FRT increased from 27.70±9.08cm to 47.00±5.70cm in task-oriented circuit training for balance improve- ment but such increase was not statistically signifi- cant(24). However, the present study obtained more significant result than those of previous studies on auditory intervention. TUG significantly decreased from 43.00±25.75 seconds to 39.87±26.28 seconds
in group 2(p<.05) and from 49.00±18.44 seconds to 30.85±12.74 seconds in group 3(p<.01). Dean et al.
performed a TUG test to compare dynamic balance ability through circuit exercise and observed that their circuit exercise group balance ability improved from 27.4±23.2 seconds to 19.5±14.1 seconds(13).
Song et al. noted that the result of TUG test con- ducted in order to examine dynamic balance ability in circuit exercise and traditional exercise groups was that the former's TUG more greatly increased to an average of 5.00±4.33 seconds relative to the lat- ter at an average increase of 2.12±1.74 seconds(27).
Bogle and Newton reported that enhancement in lower limb muscle strength was associated with improvement in gait velocity(28). According to the present study result, the time taken to walk 10m significantly decreased in all groups from 56.14±
52.19 seconds to 51.65±52.80 seconds(p<.05) in group 1, from 42.45±30.15 seconds to 39.83±29.81 sec- onds(p<.05) in group 2, and from 40.88±26.21 sec- onds to 29.15±20.06 seconds(p<.01) in group 3. Dean et al. reported that the time taken to walk 10 m decreased from 18.2 seconds to 14.1 seconds in their circuit exercise group, which was a larger change than that of group 3 of the present study from 11.3 seconds to 11.2 seconds(13). Song et al. also noted that their circuit exercise group saw a greater reduction in the time taken to walk 10m by an average of 4.87
±2.22 seconds than their traditional exercise group by an average of 1.69±1.40 seconds(27). Leroux et al.
reported that task-oriented training with a gradual load increase significantly decreased the time taken to walk 10m from 25.2±14.4seconds to 20.8±10.5 seconds, which was consistent with the present study result(22).
Song et al. examined effects of visual and auditory capabilities on balance performance in different age groups; In Korean adults balance performance, their average time in balance decreased from 25.97 sec- onds with their eyes open to 23.14 seconds with their eyes open and their ears covered and from 10.45 sec- onds with their eyes closed to 10.18 seconds with their eyes closed and their ears covered(29). In their experiments, the subjects used earplugs and head- phones, which did not greatly influence their balance maintenance.
However, their result is responses to instant audi- tory stimuli and different from the result of the present study in which the subjects were exposed to sustained auditory stimuli. Auditory capabilities make it possible to hear instructions, warnings, or sounds of approaching objects and are conducive to main- tainingphysicalbalance(2).Inthepresentexperiment
as well, non-noise or white noise environments sus- tained for 7 weeks were more significantly effective than an environment without auditory intervention in improving BBS results.
This study, exposure to a white noise environment significantly increased treatment efficiency, as meas- ured by MMS and AMS of the lower extremity of the affected side. Balance adjustment capabilities and the time taken to walk 10m significantly differed between prior to and after the training in all measurement items. After the 7 weeks training, in particular, BBS significantly increased in non-noise and white noise environments than in an ordinary environment, showing obvious differences. Non-noise or white noise environments are regarded effective in improv- ing gait function during circuit balance training. In future exercise treatment for hemiplegic patients, improvement of treatment environment in considera- tion of auditory intervention will be necessary.
CONCLUSION
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
Briggs RC, Gossman MR, Birch R, Drews JE, Shaddeau SA. Balance performance among non- institutionalized elderly women. Phys Ther 1989;
69(9): 748-756.
Kim HS. Movement of Human Body. Seoul: Hyun Moon Sa 1992.
Chandler JM, Ducan PW, Studenski SA. Balance performance on the postural stress test:
Comparison of young adult, healthy elderly, and fallers. Phys Ther 1990; 70(7): 410-415.
Thaut MH. Rhythm, Music, and the Brain. Taylor
& Francis Group LLC 2005.
Thaut MH, Abiru M. Rhythmic auditory stimula- tion in rehabilitation of movement disorders: A review of current research. Music Perception 2010; 27(4): 263-269.
LaBerge D. Attentional control: brief and pro- longed. Psychol Res 2002; 66: 220-233.
Bensoussan L, Viton JM, Schieppati M, Collado H, Milhe V, Mesure S, Delarque A. Changes in postural control in hemiplegic patients after stroke performing a dual task. Arch Phys Med Rehabil 2007; 88: 1009-1015.
Stapleton T, Ashburn A, Stack E. A pilot study of attention deficits, balance control and falls in the subacute stage following stroke. Clin Rehabil 2001; 15: 437-444.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Eschenbrenner AJ Jr. Effects of intermittent noise on the performance of a complex psy- chomotor task. Hum Factors 1971; 13(1): 59-63.
Shummway-Cook A, Woollcott Marjorie H. Motor Control Trans Research Clin(4th edition).
Lippincott Williams & Wilkins 2011.
Eng JJ, Chu KS. Reliability and comparison of weight-bearing ability during standing tasks for individuals with chronic stroke. Arch Phys Med Rehabil 2002; 83(8): 1238-1144.
Neil F Gordon, Meg Gulanick, Fernando Costa, Gerald Fletcher, Barry A Franklin, Elliot J Roth, Tim Shephard. Physical Activity and Exercise Recommendations for Stoke Survivors. J Am Heart Assoc 2011; 2031-2041.
Dean CM, Richands CL, Malouin F. Task-related circuit training improves performance of locomo- tor tasks in chronic stroke: a randomized, con- trolled pilot trial. Arch Phys Med Rehabil 2000;
81(4): 409-417.
Yang YR, Wang RY, Lin KH, Chu MY, Chan RC.
Task-oriented progressive resistance strengthen training improves muscle strength and functional performance in individuals with stroke. Clin Rehabil 2006; 20(10): 860-870.
Salbach NM, Mayo NE, Wood-Dauphinee S, Hanley JA, Richards CL, Cote RA. Task-orien- tated intervention enhances walking distance and speed in the first year post stroke: a randomized controlled trial. Clin Rehabil 2004; 18(5): 509-519.
Kim JE, Lee SH. Study on the present condition of the Playrooms Environment. Kor J of Play Ther 2001; 4(1): 41-55.
Carr JH, Shepherd RB. Stroke rehabilitation:
guidelines for exercise and training to optimize motor skill. Butterworth-Heinemann. Oxford 2004.
Richards CL, Malouin F, Wood-Dauphinee S, Willams JI, Bouchard JP, Brunet D. Task-specific physical therapy for optimization of gait recovery in acute stroke patients. Arch Phys Med Rehabil 1993; 74(6): 612-620.
Duncan P, Studenski S, Richands L, Gollub S, Lai SM, Reker D, Perera S, Yates J, Koch V, Rigler SK, Johnson D. Randomized clinical trial of ther- apeutic exercise in subacute stroke. Stroke 2003;
34(9): 2173-2180.
Monger C, Carr JH, Fowler V. Evaluation of a home-based exercise and training program to improve sit-to-stand in patients with chronic stroke. Clin Rehabil 2002; 16(4): 361-367.
Joo MJ. Effects of task-oriented on depression and motor function in stroke. Dongshin University, Korea 2010.
Kim SM. The efficacy of PNF and circuit group exercise on improvement of motor function in disabled persons after stroke. Department of physical therapy graduate school of Daegu University 2004.
27.
28.
29.
versus progressive resistive exercise. Arch Phys Med Rehabil 2004; 85(10): 1613-1618.
Song WS, Park MC, Shim JM. The effect of the circuit exercise and conventional exercise on walking ability in chronic stroke. J Kor Sco Phys Ther 2010; 5(2): 193-201.
Bogle Thorbahn LD, Newton RA. Use of the berg balance test to predict falls in elderly persons.
Phys Ther 1996; 76(6): 576-583.
Song JM, Park RJ, Kim JS. The effect of vision and audition on balance performance according to age. J Kor Soc Phys Ther 1994; 6(1): 75-84.
23.
24.
25.
26.
Leroux A, Pinet H, Hadeaus S. Task-oriented intervention in chronic stroke; Changes in clinical and laboratory measures of balance and mobility.
Am J Phys Med Rehabil 2006; 85(10): 820-830.
Lee HS, Kim MC. The effect of balance task- related circuit training on chronic stroke patients.
J Kor Soc Phys Ther 2009; 21(4): 23-30.
Weiner DK, Bongiorni DR, Studenski SA, Duncan PW, Kochersberger GG. Does functional reach improve with rehabilitation?. Arch Phys Med Rehabil 1993; 74(8): 796-800.
Thielman GT, Dean CM, Gentile AM. Rehabilitat ion of reaching after stroke: task-related training
